膿毒癥集束化治療的演變

1、膿毒癥集束化治療張 舸浙江大學(xué)醫(yī)學(xué)院從屬邵逸夫醫(yī)院 中國(guó)首家經(jīng)過國(guó)際醫(yī)院 （JCI）評(píng)審公立醫(yī)院中國(guó)醫(yī)療機(jī)構(gòu)最正確雇主邵逸夫醫(yī)院下沙院區(qū)第1頁(yè)膿毒癥與多發(fā)性創(chuàng)傷、急性心肌梗塞以及卒中一樣，在嚴(yán)重膿毒癥發(fā)生最初幾個(gè)小時(shí)內(nèi)及時(shí)采取有效治療辦法，很有可能改進(jìn)預(yù)后膿毒癥患者需要緊急評(píng)定與治療第2頁(yè)Surviving Sepsis Campaign制訂了嚴(yán)重膿毒癥和膿毒癥休克診療指南。年更新20再次更新20又一次更新第3頁(yè)指南提出了6小時(shí)治療目標(biāo) a）中心靜脈壓（CVP） 812 mm Hg b）平均動(dòng)脈壓（MAP） 65 mm Hg c）尿量 0.5 mLkg時(shí) d）上腔靜脈或混合靜脈血氧飽和度（Sc

2、vo2） 70%。第4頁(yè)Early goal-directed therapy in the treatment of severe sepsis and septic shock Engl J Med. Nov 8;345(19):1368-77.Rivers E第5頁(yè)第6頁(yè)第7頁(yè) 第8頁(yè)將指南中含有明確降低病死率幾項(xiàng)關(guān)鍵內(nèi)容和治療辦法組合形成“膿毒癥集束化治療(surviving sepsis campaign bundle，SSCB)”，包含6 h和24 h集束治療。第9頁(yè)6 h集束治療包含： (1)動(dòng)脈血乳酸測(cè)定 (2)使用抗生素前留取病原學(xué)標(biāo)本 (3)早期廣譜抗生素治療 (4)早期目

3、標(biāo)性復(fù)蘇(EGDT)第10頁(yè)24 h集束治療包含： (1)小劑量糖皮質(zhì)激素使用 (2)血糖控制 (3)重組人活化蛋白C (4)肺保護(hù)機(jī)械通氣第11頁(yè)最新SSCB刪除了原有24 h集束治療，并將過去6 h集束治療更改為3 h和6 h集束治療第12頁(yè)3h集束治療包含： (1)動(dòng)脈血乳酸測(cè)定 (2)應(yīng)用抗生素前留取血培養(yǎng) (3)使用廣譜抗生素 (4)在低血壓和(或)乳酸4 mmolL時(shí)，開啟晶體液30 mlkg進(jìn)行復(fù)蘇第13頁(yè)6 h集束治療包含： (1)經(jīng)初始液體復(fù)蘇低血壓無(wú)法糾正時(shí)，應(yīng)用升壓藥品維持平均動(dòng)脈壓(MAP)65 mm Hg (2)經(jīng)初始液體復(fù)蘇血壓仍低或初始乳酸水平4 mmolL時(shí)，測(cè)

4、定CVP及ScvO2（SvO2），6 h復(fù)蘇治療定量目標(biāo)為CVP8 mm Hg，ScvO70（SvO65%） (3)假如初始乳酸水平升高，應(yīng)重復(fù)測(cè)定乳酸，復(fù)蘇治療定量目標(biāo)為乳酸恢復(fù)正常第14頁(yè)P(yáng)roCESSProMISeARISE第15頁(yè)第16頁(yè)第17頁(yè)P(yáng)rotocol-based standard therapy required adequate peripheral venous access (with placement of a central venous catheter only if peripheral access was insufficient) and admin

5、istration of fluids and vasoactive agents to reach goals for systolic blood pressure and shock index (the ratio of heart rate to systolic blood pressure) and to address fluid status and hypoperfusion, which were assessed clinically at least once an hour.第18頁(yè)During the first 6 hours, the volume of in

6、travenous fluids 2.8 liters in the protocol-based EGDT group,3.3 liters in the protocol-based standard-therapy group, and2.3 liters in the usual care group第19頁(yè)More patients in the protocol-based EGDT group than in the protocol-based standard-therapy group or the usual-care group received dobutamine

7、and packed red-cell transfusions (dobutamine use, 8.0% vs. 1.1% and 0.9%, respectively; P 70%（ProCESS研究中為71%）。ScvO2反應(yīng)是氧供和氧耗平衡，怎樣判斷患者容量狀態(tài)和心輸出量有更可靠地方法。第33頁(yè)EGDT推廣意義引發(fā)廣大醫(yī)護(hù)人員對(duì)膿毒癥重視早期識(shí)別，早期處理膿毒癥液體復(fù)蘇與容量判斷第34頁(yè)SSC指南取消了EGDT提議，本身并未對(duì)3/6小時(shí)集束化內(nèi)容進(jìn)行詳述SSC官網(wǎng)專門設(shè)置了一個(gè)Bundles網(wǎng)頁(yè)，以供最新集束化指南更新，基于EDGT臨床試驗(yàn)結(jié)果，SSC在其官網(wǎng)上公布了對(duì)版集束化治療修

8、改，但只是對(duì)6小時(shí)集束化治療中第二點(diǎn)做了更新第35頁(yè)集束化目標(biāo)修訂TO BE COMPLETED WITHIN 3 HOURS:1) Measure lactate level2) Obtain blood cultures prior to administration of antibiotics3) Administer broad spectrum antibiotics4) Administer 30 ml/kg crystalloid for hypotension or lactate 4mmol/L第36頁(yè)集束化目標(biāo)修訂TO BE COMPLETED WITHIN 6 HOUR

9、S:5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) 65 mm Hg6) In the event of persistent hypotension after initial fluid administration (MAP 2mmol/L), it should be remeasured within 24 h to guide resuscitation to

10、normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion第45頁(yè)抗生素使用前獲取血培養(yǎng)Sterilization of cultures can occur within minutes of the first dose of an appropriate antimicrobial , so cultures must be obtained before antibiotic administration to optimize the identifica

11、tion of pathogens and improve outcomes第46頁(yè)Appropriate blood cultures include at least two sets(aerobic and anaerobic). Administration of appropriate antibiotic therapy should not be delayed in order to obtain blood cultures.第47頁(yè)廣譜抗生素使用Empiric broad-spectrum therapy with one or more intravenous antim

12、icrobials to cover all likely pathogens should be started immediately for patients presenting with sepsis or septic shock.第48頁(yè)液體復(fù)蘇膿毒癥患者伴或不伴休克、乳酸升高，均需要立馬開始液體復(fù)蘇最少30ml/kg晶體液3小時(shí)內(nèi)完成第49頁(yè)第50頁(yè)We randomly assigned children with severe febrile illness and impaired perfusion to receive boluses of 20 to 40 ml o

13、f 5% albumin solution (albumin-bolus group) or 0.9% saline solution (saline-bolus group) per kilogram of body weight or no bolus (control group) at the time of admission to a hospital in Uganda, Kenya, or Tanzania。第51頁(yè)第52頁(yè)Fluid boluses significantly increased 48-hour mortality in critically ill chil

14、dren with impaired perfusion in these resource-limited settings in Africa.第53頁(yè)There are only limited data to support the use offluidbolustherapy in hospitalized children.FluidBolusTherapy-Based Resuscitation for SevereSepsisin Hospitalized Children: A Systematic Review.Pediatr Crit Care Med. Oct;16(8):e297-307.第54頁(yè)縮血管藥品使用Urgent restoration of an adequate perfusion pressure to the vital organs is a key part of resuscitation.